1699730655 NPI number — MADELYN J JACOBS MD

Table of content: MADELYN J JACOBS MD (NPI 1699730655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699730655 NPI number — MADELYN J JACOBS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBS
Provider First Name:
MADELYN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699730655
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776351
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-588-9490
Provider Business Mailing Address Fax Number:
502-272-5116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4950 NORTON HEALTHCARE BLVD
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40241-2845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-394-6200
Provider Business Practice Location Address Fax Number:
502-394-6210
Provider Enumeration Date:
04/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  19774 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000052154N . This is a "HUMANA - CMA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50007053 . This is a "PASSPORT - CMA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2448228000 . This is a "PASSPORT ADVTG - CMA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64197742 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017347 . This is a "SIHO - CMA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1198337 . This is a "CHA - CMA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: P00176889 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000350622 . This is a "ANTHEM - CMA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 6980512-006 . This is a "CIGNA - CMA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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